Breast Cancer

BREAST CANCER
Breast cancer is a major health problem in the United States. At present, there is no cure. It
is estimated that more than 190,000 women and 1900 men develop the disease and more
than 40,000 die of it annually (ACS, 2009). Incidence rates, however, have decreased by
3.5% per year from 2001 to 2004 after increasing since 1980. Between 1990 and 2002, the
mortality rate for breast cancer decreased by 2.2%, suggesting that the combination of early
detection and improved treatment modalities had an effect on overall survival.
Current statistics indicate that over an entire lifetime (birth to death), a woman’s risk of
developing breast cancer is one in eight. When broken down by age, the risk by 39 years of
age is 1 in 210, and it increases to 1 in 26 by 59 years of age. Approximately 80% of breast
cancers are diagnosed in women older than 50 years of age
In the Philippines, Cancer is the 3rd cause of mortality and morbidity in the country. One
research stated that one in 1,800 Filipinos will develop cancer annually. For every two new
cases of cancer diagnoses every year, one will pass away within the year. The Philippines
has the highest number of reported of breast cancer incidence in Asia with an age
standardized incidence rate (ASR) of 47.7 per 100,000 Filipino women. This number is
higher than the numbers of some European countries like Spain and Italy.
http://www.doh.gov.ph/sites/default/files/HB00710.pdf
RISK FACTORS
There is no single, specific cause of breast cancer. A combination of genetic, hormonal, and
possibly environmental factors may increase the risk of its development
More than 80% of all cases of breast cancer are sporadic, meaning that patients have no
known family history of the disease. The remaining cases are either familial (there is a family
history of breast cancer but it is not passed on genetically) or genetically acquired. There is
no evidence that smoking, silicone breast implants, use of antiperspirants, underwire bras, or
abortion (induced or spontaneous) increases the risk of the disease.
 Female Gender - 99% of cases occur in women.

 Increasing Age - Increasing age is associated with an increased risk.
 Personal history of breast cancer - Once treated for breast cancer, the risk of
developing breast cancer in same or opposite breast is significantly increased.
 Family history of breast cancer - Having first-degree relative with breast cancer
(mother, sister, daughter) increases the risk twofold; having two first-degree relatives
increases the risk fivefold. The risk is higher if the relative was premenopausal at the
time of diagnosis. The risk is increased if a father or brother had breast cancer (exact
risk is unknown).
 Genetic mutation - BRCA1 and BRCA2 mutations account for the majority of
inherited cases of breast cancer
 Hormonal Factors
 Early menarche - Before 12 years of age
 Late menopause - After 55 years of age
 Nulliparity - No full-term pregnancies
 Late age at first full-term pregnancy - After 30 years of age
 Hormone therapy (formerly referred to as hormone replacement therapy) -
Current or recent use of combined postmenopausal hormone therapy
(estrogen and progesterone). Long-term use (several years or more)
 Exposure to ionizing radiation during - The risk is highest if breast tissue was
exposed while still developing (during adolescence) such as adolescence and
early adulthood women who received mantle radiation (to the chest area) for
treatment of Hodgkin lymphoma in their younger years.
 History of benign proliferative breast disease - Having had atypical ductal or

lobular hyperplasia or lobular carcinoma in situ increases the risk
 Obesity - Obesity and weight gain during adulthood increases the risk of
postmenopausal breast cancer. During menopause, estrogen is primarily produced in
fat tissue. More fat tissue can increase estrogen levels, thereby increasing breast
cancer risk.
TYPES OF BREAST CANCER
1. Ductal Carcinoma in Situ DCIS is characterized by the proliferation of malignant

cells inside the milk ducts without invasion into the surrounding tissue. Therefore, it is
a noninvasive form of cancer (also called intraductal carcinoma).
2. Invasive Cancer
 Infiltrating Ductal Carcinoma Infiltrating ductal carcinoma, the most common
histologic type of breast cancer, accounts for 80% of all cases. The tumors arise
from the duct system and invade the surrounding tissues. They often form a solid
irregular mass in the breast.
 Infiltrating Lobular Carcinoma Infiltrating lobular carcinoma accounts for 10%

to 15% of breast cancers. The tumors arise from the lobular epithelium and
typically occur as an area of ill-defined thickening in the breast. They are often
multicentric and can be bilateral.
 Medullary Carcinoma Medullary carcinoma accounts for about 5% of breast

cancers, and it tends to be diagnosed more often in women younger than 50
years of age. The tumors grow in a capsule inside a duct. They can become large
and may be mistaken for a fibroadenoma. The prognosis is often favorable.
 Mucinous Carcinoma Mucinous carcinoma accounts for about 3% of breast

cancers and often presents in postmenopausal women 75 years of age and
older. A mucin producer, the tumor is also slow growing and thus the prognosis is
more favorable than in many other types.
 Tubular Ductal Carcinoma Tubular ductal carcinoma accounts for about 2% of

breast cancers. Because axillary metastases are uncommon with this histology,
prognosis is usually excellent.
 Inflammatory Carcinoma Inflammatory carcinoma is a rare (1% to 3%) and

aggressive type of breast cancer that has unique symptoms. The cancer is
characterized by diffuse edema and brawny erythema of the skin, often referred
to as peau d’orange (resembling an orange peel). This is caused by malignant
cells blocking the lymph channels in the skin. An associated mass may or may
not be present; if there is a mass, it is often a large area of indiscrete thickening.
Inflammatory carcinoma can be confused with an infection because of its
presentation. The disease can spread to other parts of the body rapidly.
Chemotherapy often plays an initial role in controlling disease progression, but
radiation and surgery may also be useful.
 Paget’s disease Paget’s disease of the breast accounts for 1% of diagnosed

cases of breast cancer. Symptoms typically include a scaly, erythematous,
pruritic lesion of the nipple. Paget’s disease often represents ductal carcinoma in
situ of the nipple but may have an invasive component. If no lump can be felt in
the breast tissue and the biopsy shows DCIS without invasion, the prognosis is
very favorable.
CLINICAL MANIFESTATIONS
Breast cancers can occur anywhere in the breast but are usually found in the upper outer
quadrant, where the most breast tissue is located.
 Nontender rather than painful
 Fix rather than mobile
 Hard, irregular borders rather than encapsulated and smooth
 Assess AVON:
 Asymmetrical
 Venous prominence
 Orange peel skin
 Nipple dimpling
ASSESSMENT AND DIAGNOSTIC EXAMS

1. BSE
2. Biopsy
STAGING
Staging involves classifying the cancer by the extent of disease. Clinical staging involves the
physician’s estimate of the size of the breast tumor and the extent of axillary lymph node
involvement. Such staging is determined by physical examination and imaging studies.
Pathological staging is done when the pathologist examines the surgically excised breast
tissue under the microscope and determines the exact size of the breast tumor and the exact
number of lymph nodes involved.
0 – DCIS Ductal Carcinoma in Situ (cortex)

Lumpectomy/Total Mastectomy
I – 0-2 cm
Breast Conservation Treatment/Modified Radical Mastectomy
II – 2-5 cm
Breast Conservation Treatment/Modified Radical Mastectomy
III - >5 cm
Modified Radical Mastectomy
IV – metastasis
Lumpectomy/ Modified Radical Mastectomy
SURGICAL MANAGEMENT
1. Modified Radical Mastectomy - is performed to treat invasive breast cancer. The

procedure involves removal of the entire breast tissue, including the nipple–areola
complex. In addition, a portion of the axillary lymph nodes are also removed in
axillary lymph node dissection (ALND). If immediate breast reconstruction is desired,
the patient is referred to a plastic surgeon prior to the mastectomy so that she has
the opportunity to explore all available options. In modified radical mastectomy, the
pectoralis major and pectoralis minor muscles are left intact, unlike in radical
mastectomy, in which the muscles are removed. Radical mastectomy is rarely
performed today.
2. Total Mastectomy - Like modified radical mastectomy, total mastectomy (ie, simple
mastectomy) also involves removal of the breast and nipple–areola complex but does
not include ALND. Total mastectomy may be performed in patients with noninvasive
breast cancer (eg, DCIS), which does not have a tendency to spread to the lymph
nodes. It may also be performed prophylactically in patients who are at high risk for
breast cancer (eg, LCIS, BRCA mutation). A total mastectomy may also be
performed in conjunction with sentinel lymph node biopsy (SLNB) for patients with
invasive breast cancer.
3. Breast Conservation Treatment - The goal of breast conservation treatment (ie,

lumpectomy, wide excision, partial or segmental mastectomy, quadrantectomy) is to
excise the tumor in the breast completely and obtain clear margins while achieving
an acceptable cosmetic result.
 Lumpectomy – removal of lump
 Quadrantectomy – removal of 1 quadrant
 Wide excision - removal of a small area of diseased or problematic tissue with
a margin of normal tissue
 Partial mastectomy - involves removing the cancer from your breast with a
rim, or margin, of normal breast tissue.
 Segmental mastectomy - removal of some of breast tissue around the tumor
and the lining over the chest muscles below the tumor
4. Radical Mastectomy – removal of entire breast, lymph nodes, and pectoralis major
and minor
Post-operative Nursing Interventions:
a. Prevent lymph edema – elevate the affected side, squeeze ball/stress ball
b. Prevent infection – aseptic technique
MEDICAL MANAGEMENT
1. Tamoxifen (Nolvadex) – anti estrogen
Side effects:
 Hot flashes - Wear breathable, layered clothing. Avoid caffeine and spicy
foods. Perform breathing exercises (paced respirations). Consider
medications (vitamin E, antidepressants) or acupuncture.
 Vaginal Dryness - Use vaginal moisturizers for everyday dryness (eg,
Replens, Vitamin E suppository). Apply vaginal lubrication during intercourse
(eg, Astroglide, K-Y jelly).
 Nausea and Vomiting - Consume a bland dietary to take medication in the
evening.
PROGNOSIS
Several different factors must be taken into consideration when determining the prognosis of
a patient with breast cancer. The two most important factors are tumor size and whether the
tumor has spread to the lymph nodes under the arm (axilla). Generally, the smaller the
tumor, the better the prognosis. Carcinoma of the breast is not a pathologic entity that
develops overnight. It starts with a genetic alteration in a single cell and takes time to divide
and double in size. A carcinoma may double in size 30 times to become 1 cm or larger, at
which point it becomes clinically apparent. Doubling time varies, but breast tumors are often
present for several years before they become palpable. Nurses can reassure patients that
once breast cancer is diagnosed, they have a safe period of several weeks to make
decisions regarding treatment.

Breast Cancer

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BREAST CANCER

 Female Gender - 99% of cases occur in women.

 History of benign proliferative breast disease - Having had atypical ductal or

TYPES OF BREAST CANCER

1. Ductal Carcinoma in Situ DCIS is characterized by the proliferation of malignant

 Infiltrating Lobular Carcinoma Infiltrating lobular carcinoma accounts for 10%

 Medullary Carcinoma Medullary carcinoma accounts for about 5% of breast

 Mucinous Carcinoma Mucinous carcinoma accounts for about 3% of breast

 Tubular Ductal Carcinoma Tubular ductal carcinoma accounts for about 2% of

 Inflammatory Carcinoma Inflammatory carcinoma is a rare (1% to 3%) and

 Paget’s disease Paget’s disease of the breast accounts for 1% of diagnosed

ASSESSMENT AND DIAGNOSTIC EXAMS

0 – DCIS Ductal Carcinoma in Situ (cortex)

1. Modified Radical Mastectomy - is performed to treat invasive breast cancer. The

3. Breast Conservation Treatment - The goal of breast conservation treatment (ie,

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